Presentation of Case N 3

Presentation of case n° 3

A young male with abdominal pain in the right upper abdominal quadrant.

Agostino C., 30-year-old, for the first time is suffering from a pain described as “sharp” although sometimes it presents slight variations, suggesting colic. The pain occurred rapidly, in complete healthy, after really abundant supply of food, in the right upper abdominal quadrant, spreading toward the homolateral flank. Other symptoms, as dyspepsia, vomiting, flatulance, distension due to gaseous dilation of the stomach, fever, a.s.o. are not referred by the patient, apart from slight nausea.

His mother, positive for Reaven’s “variant” syndrome (See later on), I described early (See: Bibliography, in Home Page), was operated of uncomplicated gall-stones. Patient’s father is healthy, but CAEMH-positive.

The patient, physically similar to his father, was well until the rapid onset of the disease, two days earlier.

The pain in right abdominal quadrant is brought about by a large body of causes, among them the most common are:

A) disorders hepato-biliary in origin, such as gall-stones, choledoco-lithiasis, cholangitis, cholecystitis, hepatic abscess, hepatitis, hepatomegalia secondary to stasis;

B) gastro-intestinal disorders, as appendicitis, retrocecal and/or localized in high site, hepatic flexure syndrome, duodenal diseases;

C) disorders pancreatic in origin, as acute pancreatitis of the head, head pancreatic cancer;

D) kidney diseases, like right renal colic, pyelonrephritis, kidney malignancy;

E) lung disorders, such as right basal pleurisy, pneumothorax, pulmonary embolism;

F) cardiac disease, for example, pericarditis, acute myocardial infarction

Patient’s family history gives only an interesting information, i.e. mother’s gall-stones. However, the patient physically looks very much like his father, who ,however, is also CAEMH- positive.

Clinical examination, both traditional and biophysical-semeiotic, begins evaluating:

1) the thorax, “posterior way” (See later on), in order to ascertain lungs, spleen and kidney size: right kidney is enlarged and its oscillations appear to be small (0,5 cm.); duration of renal congestion is only 5 sec. On the contrary, left kidney diameters are slight augmented and its fluctuation are maximally intense (1,5 cm.), with congestion duration of 7-8 sec.;these data provide precious information;

2) the presence of RESHS, even by means of sensitisized tests, and

3) acute phase Proteins, i.e. inflammation signs,

4) acute antibodies Synthesis Syndrome,

5) diagram of tissue-microcirculatory-unit: all these signs are negative (See: Acute Appendicitis in Practical Applications in Home-Page).

In the post-absorptive state, i.e. at least three hours after a meal and before the successive food intake, digital pressure of “light” intensity, applied on liver cutaneous projection area (= stimulating hepatic trigger-points with small intensity, in order to provoke upper, mean and lower ureteral reflexes, which allow doctor to assess their fluctuations, providing in this manner information about liver vasomotility as well as vasomotion) causes upper ureteral reflex fluctuations (=vasomotility), and lower ureteral reflex oscillations (= vasomotion) lasting 7 sec. in the liver, a time smaller than that of duration of pancreatic, biceps muscle and adipose tissue microcirculatory fluctuation : duration 8-9 sec..

These interesting microcirculatory events show normal sensitivity only of hepatic insuline-receptors, while pancreatic, striated muscle and adipose tissues insuline-receptors are hyporeactive: Reaven’s “variant” syndrome, as illustrated later on (See: Ferrero-Marigo’s Manoeuvre in Glossary and Bibliography, in Home-Page), conditio sine qua non of lithiasis.

Apart from CAEMH- and Reaven’s “variant” syndrom, the characteristic clinical phenomenology of oncological terraine is absent(See: Oncological Terrain in Home-Page).

The biophysical-semeiotic results, collected in a few minutes, allow doctor to leave outinfectious diseases as well as cancers, while they pointing out the possibility of a lithiasic disorder, because of Reaven’s “variant” syndrome represents – as stated above – the conditio sine qua non of lithiasic disorder, in whatever tissue or viscera (See: Gall-stones diagnosis in Practical Applications in Home-Page).

Clinical examination continues with evaluating gall-bladder, in order to recognize possible gall-stones (family history positive for lithiasis of cholecyst), which, however, is certainly excluded by the physiological value (lt 8 sec.) of cholecyst-gastric aspecific (-cecal, upper ureteral) reflex, as well as by cholecyst preconditioning, resulted surely normal.

The physiological form and size of cutaneous projection area of choledocus permit to leave out the diagnosis of choledocolithiasis. In addition, cutaneous-choledocus reflexes (= in health, persistent pinching with “mean-high” intensity of the skin at left or right side of choledocus projection provokes choledocus dilation) appear to be normal and “velocimetry” of biliary tract peristaltic wave, starting from the gall-bladder fundus, shows the physiological value of 5 sec., allowing doctor to exclude both gall-stones and choledocolithiasis (= in healthy, pinching for only 1-2 sec. the skin of projection area of cholecyst “fundus” originates locally a peristaltic “jatrogenetic” wave, that reaches Oddi’s sphincter in 5 sec.). As a matter of facts, gallstones are more common in women than men, but there appears to be an increase in the frequency of gallstones, apart from wide geographical variation in their prevalence (See Gallstones Diagnosis in Practical Applications, in Home-Page).

From the biophysical semeiotic point of view, all these epidemiological data (and many others, too) are now-a-day without any importance, as far as clinical diagnosis is concerned.

Since the numerous biophysical-semeiotic signs of inflammation are not detected, the diagnosis of cholangitis, cholecystitis, liver abscess, viral hepatitis can be surely left out.

Acute retrocecal appendicitis or appendicitis localized in upper abdominal quadrant can be easily and certainly excluded from differential diagnosis because RESHS, “complete” type, and other numerous, sensitive and specific, signs of this disease are absent: negative particularly Berti-Riboli’s Sign and Bella’s Sign, characteristic of retrocecal appendicitis (See: Acute Appendicitis in Practical Applications in Home Page)..

Acute pancreatitis of the head is always accompanied by Acute Phase Proteins and a lot of other inflammatory biophysical-semeiotic signs, absent in this case, besides specific signs of pancreatitis (See: Bibliography in Home-Page). Moreover, pancreatic cancer, although very rear in a young man, can be easily excluded, as oncological terrain is absent.

Acute pleurisy is obviously accompanied by well known inflammatory signs, here absent, illustrated above; polmonary embolism, a disorder often difficult to be recognized at the bed-side, presents pleuritic pain, dyspnea, tachycardia, and characteristically – from biophysical-semeiotic point of view – increasing of the time of blood passage through the lungs macro- and micro-vessels (NN = 5 sec., estimated as duration of disappearing of hepato-ureteral “in toto” reflex, and subsequent reinforcements, caused by intense digital pressure on cutaneous projection area of liver). In the patient the value of this interesting parameter is 5 sec., i.e. normal.

The clinical abundant symptomatology of Acute Myocardial Infarction and Acute Pericarditis is absolutely absent in the patient, whose “cardiogram” appears to be normal, cardiac-gastric aspecific(-cecal,- upper ureteral) reflexshows lt 6,5 sec. (NN  6 sec.) and myocardial preconditioning is physiological (See: Practical Applications in Home-Page and Presentation Case 1°).

Finally, doctor must evaluate the right kidney, in order to ascertain a renal colic, caused by kidney stone, since infectious and neoplastic disorders have been excluded, as described above.

It is worth recommending, as a routine action, to beginn clinical examination, in both traditional and biophysical-semeiotic manner, starting from assessement of the thorax “posterior way”; in this case, doctor collects following data:

1) the health left kidney shows a “renogram” characteristic of vagal hypertonus (See: Practical Page 3 in Home-Page): fluctuations are all highest, i.e. Highest Spikes, and therefore Phase C/Phase D > 1. On the contrary, the renogram of right kidney, intensely dilated as occurs in high obstructve uropathy, presents small oscillations, lasting only 5 sec. (NN = 6 sec.), allways identical, without typical chaotic-deterministic behaviour , which shows physiological condition.

In other words, diseased kidney works less than normal, “as does an ill worker, who rest in his house, possibly at bed “, while healthy kidney is working intensively, providing more glomerulare filtration rate, sufficient to balance the functionally damaged kidney.

At this point the reader must pay attention on an interesting event, which , at the moment of discovering these facts, provided me some mistakes, particularly in attributing the real site of colic: soon after urinary ostruction disappearing, due to spontaneous stone elimination, ”renal diagrams” reverse their pattern, illustrated above, in the sense that the formerly diseased kidney is working more intense than the other, as do, once again, the workers: a model behaviour of the marvels of Nature. Consequently, doctor, who lacks of experience, could diagnose erroneously the side of diseased kidney.(This topic will be descussed in details in my book, BiophysicalSemeiotics. Clinical Microangiology).

With the suspected diagnosis of right renal colic, urolithiasis, clinical examination of right kidney continues:

2) the simulated urinaton test appears to be extremely positive (See: Bibliography in Home-Page,

3) the volume of right kidney is modified, because of size increasing: its diameters are clearly enhanced. In addition, there is dilation of homolateral urether, apart a small segment, near to lower ureteral sphincter.

4) right renal-gastric aspecific reflex shows lt of only 4 sec. (NN = 8 sec.) and consequentially preconditioning of right kidney results pathological.

5) right renal-left ureteral reflex (“in toto”), caused by “mean-intense” digital pressure, of 3 cm., is persistent without the characteristic lowering of one third of its intensity (= lithiasis), corroborating right ureteral dilation as well as absence of stones in right kidney, at this moment.

6) As fas as renal vasomotility and vasomotion are concerned (I will illustrate this topic in next future, due to the reader’s lak of biophysical semeiotic knowleges, that are nedeed.), it is enough for the moment to know that “small” digital pressure on cutaneous projection area of a kidney (= skin of lateral abdomen surface) provokes upper (= arterioles and little arteries, according to Bucciante), middle (= interstitium) and lower (= nutritional capillaries and post-capillary venules) ureteral reflexes, which fluctuate slightly, in identical manner, i.e. without chaotic-deterministic behaviour: microcirculatory dysactivation.

7) Of great interest, helix-gastric aspecific (-cecal) reflex shows lt 4 sec. (NN = 10 sec.), suggesting the increase of uric acid metabolic pool, characteristic biophysical-semeiotic sign of renal colic.

In the presentation of this case, I spoke about the Reaven’s “variant” syndrome, I described previously (See: Bibliography in Home Page), conditio sine qua non of lithiasis, in whatever biological system: kidney, liliary tract, salivary glands, , prostate, arterial wall, a.s.o.

In other words, in the absence of this syndrome there are no stones in tissue, organ or viscera.

The interesting fact, for instance, allows to comprehend the intense calcium deposit in arterial wall in Moenkemberg disease, beside a large number of arteriosclerosis cases without any calcification, apart from disease seriousness. Identical results can be collected bed-side in case of cancers, when we observe a large number of tumour, but not all, with some degree of calcification.

Reaven’s “variant” syndrome is characterized by physiological responsiveness of insuline receptors exclusively in the liver, while identical receptors in adipocytes and striated muscle cells are hypo-responsive, showing variations in intensity.

Doctor can evaluate the degree of activity of insulin-receptors in above-mentioned tissues, in diverse manner, very different in difficulty (See: Ferrero-Marigo’s Manoeuvre in Glossary and Biography, in Home-Page).

An easy evaluation is the following: in healthy, during stimulating acute insuline secretion pick (= pinching the skin of VI thoracic dermathomere for 15 sec. exactly, i.e. about the skin covering costal arch, where it crosses hemi-clavear line), after 5 sec. from its starting, liver size augments (= inferior hepatic margin lowers of about 2,5 cm.) lasting for 12 sec. (= lt pancreatic-gastric aspecific reflex, i.e. 12 sec.: interne and externe coherence of the biophysical-semeiotic theory). On the contrary, only in Reaven’s variant syndrome, duration of inferior hepatic margin lowering appears to be clearly > 2,5 cm. and lasts > 12 sec., because of hyper-insulinemia-insulinresistance, apart liver cell receptor, of course.

Clinical diagnosis is: right renal colic, urolithiasis.

This diagnosis is sometime very difficult to make, even as regards specialists of urology, and similar diagnosis are made, like “colon spasms”, “vertebral arthrosis”, “appendicitis, as allows me to state a long experience. The numerous, specific and sensitive biophysical-semeiotics signs permit doctor to recognize easily in a few minutes urinary stones, even silent.